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gynaecology
Final Year Revision
Mark Breakdown
200 Marks
40: continuous assessment
80: Viva
80: End of year exam
8 SAQs
40 MCQs
Gynaecology
Urogynaecology
Gynae-oncology
Fertility
General gynaecology (inc. contraception)
Quick review
OBSTETRICS
Miscarriage
Stillbirth
Ectopic
APH
Fetal medicine
Antenatal screening
Vertical transmission
At risk fetuses
Monitoring during
pregnancy
Maternal medicine
Maternal conditions of
pregnancy
Gestational diabetes
VTE
PET
Sepsis
Psychiatric
Labour ward
DISORDERS OF EARLY
PREGNANCY
Ectopic pregnancy
Incidence
Worldwide, remains the
leading cause of maternal
death in first trimester
14.8/1000 maternities
(HIPE, 2012)
Accounts for 6% maternal
deaths
Risk factors
Infertility (2x RR)
Tubal pathology (3x RR)
Documented salpingitis
(4x RR)
Pregnancy with previous
sterilisation or IUD in situ
Previous ectopic (10%
recurrence if one previous,
Presentation
5% present in
haemorrhagic shock
Pain, PV bleeding
Diarrhoea, dizziness
Ectopic-Ix
TVUS
Discriminatory zone
>1500
60% ectopics seen
as a
nonhomogenous
mass adjacent to
the ovary
Bagel sign
(hyperechoic ring)
in 20%
13% gestational sac
with fetal pole
Management of ectopic
Expectant
Minimal symptoms
Will comply with follow up
hCG<1000 and falling
Medical
Methotrexate (DHFR
inhibitor) IM. Calculate by
body weight
C/I: blood dyscrasia, TB,
HIV, hepatic or renal
disease
Wait three months before
trying for pregnancy
again
Surgical
hCG>1500
Visible EP sac with cardiac
activity
Mass>35mm
Unstable patient
Laparoscopic or
laparotomy
Salpingectomy or
salpingotomy
No significant difference in
fertility or incidence of
recurrent of ectopic
For all mx
Follow hCG until it reaches
non pregnant levels
Anti D (250) if Rh-
Miscarriage
Pregnancy loss <24 weeks gestation
or <500g
10-20% pregnancies
Divided into first trimester (<12
weeks, 80%) and second trimester
(late, 0.5% risk in low risk women)
50% miscarriages are due to a non
recurrent chromosomal abnormality
Miscarriage-risk factors
Maternal
Age, smoking, obesity, alcohol, cannabis,
cocaine
Infection
Toxoplasmosis, varicella, listeria, malaria, CMV
Medical conditions
Diabetes, SLE, AIDS, Ebola (!)
Anatomical
Uterine abnormalities, conization, cervical
weakness
Miscarriage-presentation
Abdominal pain and pv
bleeding
Differential
Miscarriage
Ectopic
Ruptured CL cyst
GTD
Degenerating fibroid
Ovarian torsion
PID
Endometriosis
Local bleeding (cervical,
vaginal
Heterotopic pregnancy
Initial Mx and Ix
Stabilise
Focused history and
exam
hCG, TVUS, serum
progesterone
Progesterone: <25mmol/lassociated with
pregnancies subsequently
confirmed to be non viable
Beta hCG should double in
48 hours. Discriminatory
zone >1500.
Types of miscarriage
Missed/delayed
Fetal demise, no uterine activity.
Empty sac (mean gestational sac diameter>20mm with not fetal
pole OR no fetal heart with fetal pole>7mm)
Complete
All products of conception passed
Intrauterine tissue diameter <15mm
Inevitable
Open os, POC not expelled
Threatened
PV bleed, closed os
Viable pregnancy
Septic
+infection
Management
Conservative/expectant
Successful in 2-6/52 in >80%
incomplete, 30-70% missed
40-50% women will choose
Repeat U/S 10-14 days post
event to ensure miscarriage is
complete
Medical
Misoprostol 2x600mcg, 6
hours apart (PGE1 analog)
Mifepristone (progesterone
antagonist)
Success: >80% incomplete, 4090% delayed
Medical/expectant mx in
women with 24 phone access,
ED nearby, gestational
sac<50mm
Surgical (ERPC)
Success>95%
Suction curettage
Indications
Patient preference
Heavy PV bleeding
Septic miscarriage
Haemodynamic instability
?GTD
Risks
Infection 0.2%
Bleeding 1%
Damage to local structures
(uterine perforation 1/250)
Retained POC (1% need a
repeat ERPC)
Recurrent miscarriage
>3 consecutive
trimester losses
Primary: no previous
successful pregnancy
Secondary: prior pregnancy
reached viability
Early
70% idiopathic
4% genetic: parental
karyotype. Rx: prenatal
diagnosis, or IVF and
preimplantation screen
Anatomical abnormalities:
hysteroscopy
Antiphospholipid antibodies
Late
Cervical incompetence
(Shirodkar cerclage)
Infection (*bacterial
vaginosis)
Causes
Fetal structural abnormalities (26% stillbirth)
Placental conditions (24% stillbirth)
Maternal uterine abnormalities
Cervical insufficiency
Thrombophilia: FVL, Protein C/S deficiency, prothrombin mutation,
APL
Infection
PET
GDM
Obstetric cholestasis
APH: vasa praevia, abruption, PP, trauma
Management
Exam
Vital signs, Abdominal exam, speculum
+/- vaginal exam (*only if membranes
unruptured)
Ix:
Labs:
FBC, U+E, LFT, CRP
Coag, fibrinogen (sepsis, abruption, PET),
group+screen, Kleihauer,
Cx-urine, blood, swabs
Management
Delivery
NB NB Infection
Fetal demise + ROM, cervical dilatation-induce
Medical: induce with mifepristone 200mg,
misoprostol (SE: fever, NVD, contractions). Delivery
occurs within 24 hours of IOL in 90%
Expectant mx an option if
Physically well
Closed cervix, intact membranes, no PET
85% deliver spontaneously within 3/52 of diagnosis
10% risk coagulopathy 4/52 after fetal demise
Investigations
Maternal
FBC, U+E, CRP, bile
acids, LFTs, uric acid
Coag
Thrombophilia screen
TFTs
HbA1c, random blood
glucose
Serology
Toxicology
Karyotype (+paternal)
Swabs: cx, blood cx
Foetal
Cord/cardiac blood
Microbiology
Karyotype (6% will
have an
abnormality)
Placenta+membran
es
Autopsy
*50% no cause
found
APH
Causes
Placenta praevia
Placental abruption
Velamentous
insertion of cord
Vasa praevia
Local genital tract
trauma
60% have no
identified risk factor
Risk factors
Abruption
Hypertension
Substance misuse (cocaine,
smoking)
Trauma
Previous abruption
Parity
Polyhydramnios
Multiple gestation
IOL
ECV
Praevia
Prior PP
Multiple gestation
Multiparity
Prior uterine instrumentation or
surgery
Uterine anomalies
Advance maternal age
Placenta praevia
Grades
1: in lower segment but
doesnt reach os (>2cm)
2: abuts the os
3: covers the os
4: lies centrally over the os
Complications
Maternal
APH
PPH
Intrapartum hemorrhage
Massive transfusion
Shock and death
DIC
Renal failure
Sheehans syndrome (necrosis of
anterior pituitary)
Invasive implantation
Foetal
Distress
HIE
Anaemia
Death
Iatrogenic premature delivery
Placental abruption
Rate: 1/120.
Presentation
Abdominal pain
+/-PV bleeding
Woody uterus
Abdominal tenderness
Hypovolemic shock
Remember, a pregnant woman
can lose 30-40% blood volume
before becoming symptomatic
Ix
Clinical diagnosis
Ultrasound will miss of
abruptions
Mx
Call for help
ABC and stabilise
Labs: Group and X match, FBC,
coag, Kleihauer
Assess foetus
TAUS
CTG >28/40
Steroids 24-33+6/40
MgSO4 for neuroprotection<32
weeks if delivery required
Anti D if Rh-ve
Invasive implantation
Placenta accreta
Abnormally adherent placenta
Increta
Placenta invades myometrium
but not serosa
Percreta
Placenta passes through
serosa and adjacent structures
Risk factors
Previous uterine
instrumentation
Complications
PPH
Hysterectomy
Uterine inversion
Failure to remove
placenta completely
Sepsis
Choriocarcinoma
FETAL MEDICINE
Ultrasound
Confirm gestation
Dating scan
CRL up to 14 weeks, then
Hadlock measurements
Location of pregnancy
Intrauterine, ectopic
Placenta
Praevia
Diagnosis
Structural abnormalities
Aid in
CVS
Amniocentesis
Fetal procedures
e.g transfusion
Laser ablation in
TTTS
Antenatal screening
20 week anatomy scan
Cardiac anomalies
1% pregnancies
Risk: Congenital cardiac disease, previous baby affected (recurrence
3%), diabetes, other structural abnormalities
Increased nuchal translucency
Renal defects
Potters sequence: renal agenesis->oligohydramnios->pulmonary
Other screening
All optional
Non invasive (examples for
T21)
Triple test
Increased beta hCG, increased
inhibin, decreased PAPP-A
Nuchal translucency
Increased NT (>6mm), absent
nasal bone, absent flow in DV)
Quad screen
Increased hCG, increased inhibin,
decreased AFP, decreased
unconjugated E2
Invasive
Chorionic villus
sampling
11/40
Risk fetal limb
reduction
2-3% risk miscarriage
Amniocentesis
15-16/40
1% risk miscarriage
Use fibroblasts for
karyotype
Vertical transmission
HIV
Interventions have reduced
the rate of HIV vertical
transmission to <1%
Transmission highest in
labour
Maternal HAART from T2
Aim for undetectable viral
load
Vaginal delivery possible
Breastfeeding
contraindicated
START for infant
(zidovudine)
Hepatitis B
dsDNA
95% risk vertical
transmission (vs 4%
for Hep C)
High risk: maternal
HBeAg +ve,
indicates high
disease activity
Rx: neonatal hep B
vaccination and Ig
Vertical transmission
Toxoplasmosis
15% population
already immune
Foetal/neonatal effects
Chorioretinitis
Intracranial calcification
Hydrocephalus
Rx: spiramycin
Risk of transmission
increases with
gestation
T1: 14%
T2>50%
Varicella
90% population already
immune
0.12/1000 live births
affected
>28/40: 0% risk
transmission
Foetal effects
Segmental limb scarring
Management
Exposure and mother non
immune: VzIG +/- aciclovir
Rash 7 days before or after
delivery: neonatal VzIg
Vertical transmission
Rubella
ssRNA
98% immune
Foetal effects
PDA, hearing loss
(Organ of Corti),
microcephaly,
cataracts
Risk of transmission
decreases with
gestation
T1: 90%
T2: 0%
Parvovirus B19
0.25% women infected in
pregnancy
Regular U/S for 6/52 if IgM
+ve
Anaemia
Monitor fetal movements
Syphilis
RPR, FPA
Numerous fetal effects
Sabre shins, mulberry
molars, cardiac anomalies,
snuffles
Transmission risk
increases with gestation
Rx: Maternal penicillin
Vertical transmission
CMV
30% already immune
40% vertical
transmission of which
10% will have
cytomegalic inclusion
disease at birth
Foetal effects
Blueberry muffin baby,
hepatosplenomegaly,
jaundice, sensorineural
hearing loss
HSV 1+2
90% population already
exposed
First outbreak in
pregnancy: <6 weeks prior
to delivery-C/S
Rx: aciclovir
Chlamydia and gonorrhea
Ophthalmia neonatorum
Gonorrhea: day 2-3,
purulent exudate
Chlamydia: day 4-5, clear
exudate. Also risk of
pneumonitis
FGR
Only 1/3 FGR
pregnancies are
recognised
prenatally
8x increase in
stillbirth
Risk of adverse
outcome
<3rd centile
Abnormal UA
measurements
Causes
Normal small
Constitutional
Symmetrical
Abnormal small
Symmetrical
Chromosomal
Vertical infection
Asymmetrical
Placental
insufficiency
Brain sparing
FGR
Mx
High risk: scan 2-4 weekly
from 26 weeks
Customised centiles
Anatomy scan
20-22 weeks
Association of IUGR and
genetic syndromes, aneuploidy
and intrauterine infection
Concomitant structural
abnormalities, polyhydramnios
or soft markers
Surveillance growth
scans
Look at fetal soft markers,
placental pathology, AFV
and UA dopplers
Delivery
SGA with no other
abnormalities
IOL or elective delivery at
37-38 weeks
Doppler abnormalities
Increased pulatility index
Absent end diastolic flow
Reversed end diastolic flow
FGR Delivery
If UA Doppler increased pulsatility
index (>95th centile):
Weekly monitoring.
Delivery no later than 37 weeks
IOL is possible with careful CTG
monitoring.
PORTO study mean time-to-delivery
interval: 26 days
Multiple pregnancy
Maternal
Fetal
Prematurity (50% tiwns, 90% triplets)
Malpresentation
Growth discordance: 18% increases
perinatal morbidity
Difficult birth
Interlocking
Specific complications
Determine chorionicity at 12 weeks
Lambda sign-DCDA
T sign Monoamniotic
MCMA
Highest risk overall
Less TTTS than MCDA
20% deliver<32 weeks
Delivery
ESPRIT study (Ireland)
Uncomplicatied monochoirionic may
continue to 37/40, dichorionic to 38/40
Reduces risk of neonatal morbidity fom
88% to 9%
4: Hydrops fetalis
5: Fetal demise of one or
both twins
Rx
Laser
photocoagulation of
placental
anasomoses <26
weeks
Oligohydramnios
Single deepest
pocket<2cm
Causes
Maternal
Medications e.g ACE
Placental
Uteroplacental insufficiency
(PET, smoking ,substance
misuse)
Fetal
FGR with brain sparing
Renal tract anomalies e.g
agenesis, posterior urethral
valves
Pregnancy related
PPROM
Post dates
Complications
Pulmonary hypoplasia
Potters sequence
Cord compression
Increased adverse
outcomes
Mx
Admit
R/O ROM
Fetal U/S :*Umbilical
doppler
Maternal hydration
Treat the cause
Polyhydramnios
Liquor pool>8cm or
AFI>95th centile
1% all pregnancies
2-5x increased perinatal
mortality
Causes
Maternal
Diabetes
Renal failure
Fetal
TEF, atresia
Myotonic dystrophy
Chromosomal anomaly
Twins
TTTS
Idiopathic
Complications
PTL
Abnormal lie,
malpresentation
Cord prolapse
Abruption
PPH
Mx
Fetal assessment-U/S
Maternal OGTT
Options to decrease liquor
(if <34 weeks)
NSAIDS decrease fetal urine
output
Amnioreduction
Delivery
Vaginal usually possible
MATERNAL MEDICINE
Rhesus disease
Blood group and
antibodies at booking
and 28/40
15% Caucasian women
Rhesus ve (dd)
Chromosome 1
Anti D prevents
isoimmunisation (1.5%0.2%)
Given routinely at 28/40
(1500iu)
Given at sensitising events
within 72 hours
Sensitising events
Miscarriage>12 weeks
APH
Ectopic pregnancy
Molar pregnancy
ERPC
TOP
Invasive prenatal
procedures
CVS, amniocentesis, FBS,
external version
Rhesus disease
If mother is already
sensitised
Rhesus disease will
worsen with each
subsequent pregnancy
Fetal haemolysis and
anaemia
Measure antibody
levels every 2-4 weeks
4-15 IU/ml: moderate
risk hemolytic disease
>15 IU/ml: high risk of
hydrops
Mx
Regular fetal
ultrasound
Peak velocity in
systole of MCA
Hydrops
In utero transfusion
Restore Hb levels
Suppress
erythropoeisis
Hyperemesis gravidarum
Affects 1% pregnancies
50% those with abnormal LFTs
66% if abnormal TFTs
Complications
Maternal
Dehydration
Metabolic alkalosis
Vitamin deficiency (B1,B6)
Risk Wernickes (nystagmus, ataxia,
confusion
Mallory Weiss tear
VTE
Risk factors
Previous hyperemesis, family
history
Thyrotoxicosis
Hx motion sickness
Lower BMI
Molar pregnancy
Multiple pregnancy
Extremes of age
Dx
Fairweather criteria
Fetal
LBW, poor Apgars, PTB
Mx
Reassurance
Hydration: Hartmanns
Cyclizine/ondansetron
Supplementation (Pabrinex)
Thromboprophylaxis
Oral steroids
Doxylamine + pyridoxine (not
licenced in Ireland)
Anaemia in pregnancy
FBC: Booking and 28/40
Iron deficiency anaemia
Many women enter pregnancy with low stores
Requirement double (to 6g/day) during prengancy
Increased risk maternal infection, PP depression and heart
failure. Fetal risks-prematurity, LBW, iron def anaemia
Physiologic anaemia
Dilutional
Increased plasma volume mass relative to red cell mass
Reason for varying definitions of anaemia/trimester
T1: 11.0 g/dl
T2: 10.5 g/dl
T3: 10.0 g/dl
UTI in pregnancy
Increased susceptibility
Dilatation of ureters and renal pelvis.
Raised plasma volume and GFR
Always treat asymptomatic bacteriuria
in pregnancy
Rx: nitrofurantoin (though risk fetal
anaemia), co-amoxiclav
Decrease risk of preterm labour,
chorioamnionitis, adverse fetal
outcomes
VTE
Most common cause
direct maternal death
in most recent
triennium (MBBRACE)
High risk: 60/100 000
pregnancies
Risk assessment
Pre conceptual
At booking visit
At hospitalisation
At delivery
On discharge
Varicose veins
Haematological ocndition
Nephrotic symdorme
Paraplegia
IVDU
VTE
Transient risk factors
Hospital admission
Surgery in
pregnancy/puerperium
Immobility (>4 days)
Blood loss (>1L)
Systemic infection
PP wound infection
Hyperemesis
Dehydration
PET
Multiple pregnancy
OHSS
Assisted reproduction
Mx
>2 risk factors: LMWH
Personal history: antenatal
and 6 weeks postnatal
prophylaxis
Emergency C/S:
thromboprophylaxis until
discharge (7 days)
Documented thrombophilia:
6/52 post partum
thromboprophylaxis
Recurrent miscarriage and
APL: LMWH and aspirin
Stop LMWH when labour
commences
No regional anaesthesia until >12
hours after last dose
DVT/PE Management
Swollen leg
Compression
ultrasound
Start LMWH 1mg/kg
BD until diagnosis
excluded
SOB, haemoptysis,
signs of PE
Stabilise
Ix: FBC, U+E, coag,
LFT, CRP
CXR
To exclude other pathologies
Diabetes in pregnancy
2-3% women lose babies
due to diabetes
Pregnancy is a
diabetogenic state
Hormones: hPL,
progesterone, cortisol, GH
Lifestyle factors: less
exercise, increased calories,
increased fat deposition
Selective screening
Family history
BMI>30
Age>40
Ethnicity
PCOS
Long term steroid use
Previous big baby
Previous unexplained
perinatal death
Current glycosuria
Polyhydramnios/macroso
mia in pregnancy
Fetal implications
Increased risk miscarriage
Increased risk stillbirth
Increased risk congenital
anomalies
Cardiac anomalies,
sirenomelia and sacral
agenesis, NTDs (high dose
folate)
Macrosomia or IUGR
Polyhydramnios
Neonatal
Shoulder dystocia+palsy
Respiratory distress syndrome
Hypoglycemia
Hypocalcaemia
Polycythemia
PET
2-3% all
pregnancies
5-7% primips
Dx
BP>140/90+protein
uria (0.3g in 24
hours) after 20/40.
Resolves within
6/52 post partum
Risk factors
Nulliparity
Previous disease (15% risk
recurrence, 50% recurrence if
severe PET<28/40)
Family history
Age >40
>10 years since last
pregnancy, new partner
Obesity
Chronic hypertension
15-25% women with gestational
hypertension will develop PET
Renal disease
Diabetes
Autoimmune diseases
Increased placental mass:
twins, molar pregnancy
PET
Complications
Stroke
Eclampsia (0.05%)
Cortical blindness
Posterior reversible
encephalopathy
syndrome
ARDS, pulmonary
oedema
HELLP
Liver capsule rupture,
liver failure
DIC
Renal failure
VTE
Accounts for
5% stillbirths
10% preterm deliveries
HELLP
Haemolysis
Dark urine
Elevated LDH
DVT/PE
Prior to delivery: TEDS, LMWH
Post partum: at least 7 days LMWH
Pulmonary oedema
Fluid overload
Fluid input limited to 80ml/hour
Natural diuresis post partum
Monitor urine output
Consider frusemide
Treatment
Confirm
Sustained elevated BP
Proteinuria
24 urine collection
Protein creatinine
ration>30ng/mmol
Labs
FBC, U+E, uric acid, LFT, coag
(only if platelets are abnormal)
Fetal assessment
At dx and q4 weeks thereafter
US: weight, growth, AFI,
Doppler UA
Methyldopa
Centrally acting antihypertensive
250mg TDS. Max dose 1g TDS
Side effects: sedation, depression
Nifedipine SR
30mg/day
Delivery
Best way on the best day
HYPITAT trial: recommended
IOL>37 weeks
Take into account
Womans symptoms
Fetal wellbeing
Favourability of cervix
Severity of PET
Severe PET
Eclampsia
Severe hypertension
(BP>160
Symptomatic
Headache+visual
disturbances
Epigastric pain
Clonus
Liver tenderness
Platelets<100x10^9
ALT>50 IU
Creatinine>100 mmol/l
Mx
Admit and monitor
Regular obs
Fetal well being
US, CTG
Fluid management
Thromboprophylaxis
Severe PET
Mx
Control BP
Labetalol 200mg PO stat
30 minutes to action
Bolus labetalol 50mg IV
Labetalol infusion
Seizure prophylaxis
MgSO4 4g IV followed by
1g/hour
Magpie trial: 80% seizures
prevented by prophylaxis
Reflexes q4hours, RR
Antidote: 10ml 10% calcium
gluconate
Post natal
Eclampsia: emergency
Call for help: ocnsulatn obstetrician,
anaesthesist, neonatologist
ABC and IV access
Loading dose MgSO4 followed by
maintenance
Diazepam 5-10mg IV
Labetalol bolus
Delivery once stabilized
LABOUR WARD
Preterm labour
Regular contractions
accompanied by cervical
change <37 weeks gestation
Dx: clinical
Spontaneous preterm labour
Intact membranes (40-45%
preterm births)
Preterm prelabour rupture of
membranes (25-30% preterm
births)
Regarded as a syndrome
Infection or inflammation
Vascular disease: uteroplacental
ischaemia or haemorrhage
Uterine overdistension
Stress and other immunologically
mediated processes
Precise mechanism usually not
established
Management
Preterm labour
Pregnancy characteristics
Risk factors
Maternal risk factors
Black, African, AfroCaribbean
Interpregnancy interval of
<6 months
Nutritional status: low
prepregnancy BMI.
Family history
Previous preterm birth (2.5x
RR)
Environmental
Smoking, cocaine, heroin
Psychological or social stress
Clinical depression
Multiple births
Antepartum haemorrhage
Intrauterine infection
(mycoplasma, u urealyticum,
bacterial vaginosis)
Non genital tract infections:
pyelonephritis, pneumonia,
appendicitis
Periodontal disease
Polyhydramnios or
oligohydramnios
Maternal abdominal surgery
Maternal medical disorders:
thyroid,asthma,diacetes,
hypertension
Cervical cone biopsy
Uterine anomalies
PPROM
Preterm prelabour rupture
of membranes
Risk factors
Diagnosis
Sterile speculum and
visualisation of fluid pooling
in the posterior fornix is the
method of diagnosis used in
CUMH
This is backed up by a TAUS
showing decreased AFI
Other methods of diagnosis:
Amnisure, an immune assay
with good sensitivity, expensive
Nitrazine test (contamination
by blood, semen or vaginal
discharge can give false
results)
Ferning of fluid on slide
PPROM
Mx
Differential
Discharge
Incontinence
Bleed
Ix
Urinalysis and MSU for
microscopy and culture
Bloods: FBC, CRP, group
and save (if precipitate
delivery likely), cultures
High vaginal swab
(bacterial vaginosis), low
vaginal swab and rectal
swab (group B strep)
Trans abdominal
ultrasound
Admit
Monitoring:
I will monitor her vital signs
every 4 hours or according to
MEWS score
Bloods: twice weekly
Scans: biophysical profile,
particularly looking at AFI. Serial
growth scans
CTG: monitoring after 28 weeks
Treatment
Erythromycin 250 mg QDS for
10 days.
Kenyon et al, 2010 performed a
review and meta analysis of the
literature which showed that
this decreased perinatal
infection and prolonged
pregnancy
PPROM
Delivery
Contentious issue.
Expectant management
until 34 weeks if no
complications
Deliver after 37 weeks
Between 34-37 weeks,
Cochrane review in
2010 concluded there
was insufficient
evidence to make a
recommendation. Take it
on a case by case basis.
Complications
Maternal:
Chorioamnionitis,
sepsis, premature
labour
Fetal
Pulmonary
hypoplasia
secondary to
anhydramnios,
premature delivery
Frequent risks
Pain (9/100)
Infection (6/100)
Haemorrhage (5/1000)
Readmission
Fetal laceration
In future pregnancies
Repeat C/S (1/4)
Placenta praevia (48/1000)
Uterine rupture (27/1000)
Stillbirth (1-4/1000)
VBAC
72-76% chance of
success
Previous vaginal delivery
the biggest predictor
Cervix favourability
Previous indication for C
section
Benefits
Vaginal birth
Shorter stay
Quicker recovery
Decreased risk in future
pregnancies
Risks
Uterine rupture (1/200)
Classical C/S scar: CI
IOL: 4x increased risk
Number of previous
sections 3x increased
risk
<12 months since last
C/S
Breech presentation
3-4% pregnancies at
term
Types
Frank: flexed hips,
extended knees,
70%
Complete: flexed
hips and knees. 10%
Footling: foot or knee
presenting, 30%
Risk factors
Idiopathic
Maternal
Uterine anomalies
Grand multip
Uterine surgery
Fetal
Multiple gestation
Preterm
Fetal anomaly or aneuploidy
Congenital malformation (2x RR)
Abnormality in tone
Maternofetal
Placenta previa
Polyhydramnios
Breech presentation
Management
CTG
Left lateral tilt
Empty bladder
Nifedipine (tocolytic)
During: US guidance
After:
CTG
Anti D if Rh-
Complications
Cord compression
Transplacental haemorrhage
Abruption
Prelabour ROM
Contraindications to ECV
Previous C section or uterine
scar
History APH
PET or hypertension
Placenta previa
Oligo/polyhydramnios
Multiple gestation
Fetal anomaly
Breech presentation
Hannah Term
Breech Trial
Vaginal delivery
carries 3x RR
neonatal morbidity
and mortality
Recommend C/S for
all
Controversial
Vaginal delivery
Frank or complete
breech
>36 weeks
EFW 2500-3500
Flexed head
Continuous EFM
2 experienced
obstetricians
Ability to perform
emergency C/S if
required
Perineal tears
Risk 2-3%
RCOG classification
(Sultan et al)
1: perineal skin only
2: incolving perineal
muscles but not anal
muscles
3a: <50% external anal
sphincter
3b: >50% external anal
sphincter
3c: External and internal
anal sphincter
4: through anal mucosa
Risk factors
Long labour
Large baby
Forceps delivery
Midline eipisiotomy
Shoulder dystocia
Epidural
IOL
Nulliparity
MX
Shoulder dystocia
Bony impaction
Diagnosed when additional
maneouvres are required to
deliver the fetal shoulder after
gentle downward traction has
failed
50% occurs in normal birth
weight infants
Risk factors
Maternal obesity
Maternal weight gain in
pregnancy (>20kg, 10x RR)
Diabetes (3x RR)
Macrosomia
Short stature, small abnormal
pelvis
Previous shoulder dystocia
IOL
Intrapartum
Failure of head to
descent
Prolonged first/second
stage
Oxytocin augmentation
Instrumental birth
Head retraction between
contractions
Difficulty delivering face
and chin
Failure of restitution
Turtle sign
TIME: pH drops by 0.04
every minute
Shoulder dystocia
HELPER-R
Call for help: 20799 and
state emergency
Evaluate for episiotomy
Legs: McRoberts
Flexion, abduction, internal
rotation
Tilts maternal pelvis-horizontal
symphysis, flattens sacral
promontory
Relieves majority of cases
Suprapubic pressure
Adduct anterior shoulder,
decrease bisacromial diameter
Entry maneouvres
Rubins 2: clinicians hand enters
posteriory. Direct pressure to
posterior aspect of anterior
shoulder
Woodscrew: enter hand
anteriorly and apply direct
pressure to anterior of posterior
shoulder and attempt to rotate
DOCUMENTATION
Shoulder dystocia
Post partum care
Maternal
Prevent PPH
Observe for
perineal pain
Neonate
Resus
Paired cord
pH/lactate
Neonatal review
Complications
Maternal
Psychological trauma
PPH 11%
Uterine trauma/rupture
Perineal lacerations, tears
Transient maternal femoral
neuropathy
Symphyseal separation
Fetal
Brachial plexus injury 216%
Erbs palsy C5/6, waiters
tip
HIE
Death
Uterine rupture
0.02%
Risk factors
High parity
Multiple pregnancy
Previous uterine
trauma/surgery
VBAC
IOL
Mid/high cavity
forceps
Obstructed labour
Internal manipulation
Trauma e.g RTA
Mx
PPH
Risk factors
Antepartum
APH: abruption,
praevia
Multiple pregnancy
Grand multip
Age>40 and a primip
PET
Gestational
hypertension
Previous PPH
Obesity
Anaemia
Intrapartum
Prolonged labour
Prolonged pyrexia
in labour
Macrosomic baby
Episiotomy
Instrumental
delivery
C section
Retained placenta
PPH
>500ml blood loss
Primary
4 Ts
Tone
Uterine atony, 70%
Tissue, 9%
Retained products
Trauma, 10%
Cervical laceration
,episiotomy, uterine
rupture
Thrombin, <1%
DIC, vWF, PET/HELLPP,
infection, AFE
Secondary
Septic retained POC
Mx
Call for help
Resuscitate
Assess maintain and
monitor airway
IV access and fluid
resuscitation (IVF followed
by O-)
Take blood: group and
Xmatch, FBC, U+E, LFT,
coag, fibrinogen
Insert foley: in and out
catheterisation
Record vitals every 15
minutes
PPH
Mx continued
Stop bleed and look for
cause
Tone
Assess uterus
Fundal massage
Bimanual massage
Tissue
Inspect placenta and
membranes
Evacuate tissue: Brant
maneouvre
Trauma
Lacerations, episiotomy
Thrombin
Is blood lost clotting?
Consider AFI
Review history: thrombophilia
Medical management
Oxytocin IM 5-10 units
Oxytocin infusion 40 units
in 40ml
Ergometrine 250 mcg IM
Carboprost 250mcg IM
q15 minutes
Misoprostol 1000 mcg PR
B lynch suture
Intrauterine Rusch balloon
UAE
Hysterectomy